Post on 04-Jan-2016
description
New Technologies & Challenges in optimizing the “heart health” of Australia
Professor Simon StewartHead, Preventative Cardiology
simon.stewart@baker.edu.au
Presentation Overview
♥ The inevitable link between age & heart disease
♥ Chronic heart failure: an exemplar of poor outcomes, hope and plenty of costs!
♥ Back to the future: the potential value in better systems of care
Advanced age = symptomatic heart disease
0
5
10
15
20
45 - 54
years
55 - 64
years
65 - 74
years
75 - 84
years
> 84 years
MEN
WOMEN
0
5
10
15
20
45 - 54
years
55 - 64
years
65 - 74
years
75 - 84
years
> 84 years
Po
pu
lati
on
pre
vale
nce
(%
)
Over the average life-time, 2 in 3 men & 1 in 3 women in Western countries will develop symptomatic heart
disease
Our ageing populations
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20
40
60
80
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120
140
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00
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00
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00
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00
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Australia Canada France Greece Italy Japan Sweden UK
Po
pu
lati
on
(m
illio
n)
65 years and over
<65 years
(14% to 29%)
(19% to 31%)
(19% to 34%)
(22% to 52%)
(23% to 54%) (19% to 33%)
(21% to 36%)
(21% to 47%)
0
20
40
60
80
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120
140
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00
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00
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00
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20
00
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20
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50
Australia Canada France Greece Italy Japan Sweden UK
Po
pu
lati
on
(m
illio
n)
65 years and over
<65 years
(14% to 29%)
(19% to 31%)
(19% to 34%)
(22% to 52%)
(23% to 54%) (19% to 33%)
(21% to 36%)
(21% to 47%)
Presentation Overview
♥ The inevitable link between age & heart disease
♥ Chronic heart failure: an exemplar of poor outcomes, hope and plenty of costs!
Chronic heart failure
An “epidemic” characterised by:
♥ Damaged heart with system wide impact (lungs, kidneys & brain)
♥ Very poor quality of life: shortness of breath & fatigue
♥ Clinical instability: costly admissions!
♥ Premature death: sudden versus slow!
0 6 12 18 24 30 36 42 48 54 600.00.10.20.30.40.50.60.70.80.91.0
Heart Failure
MI
Lung
BowelProstate
Bladder
Month of follow-up
Sur
viva
l (%
)
0 6 12 18 24 30 36 42 48 54 600.00.10.20.30.40.50.60.70.80.91.0
Heart Failure
MI
Breast
Bowel
Lung
Ovarian
Month of follow-up
Sur
viva
l (%
)Chronic heart failure: More malignant than cancer?
Stewart et al. Eur J Heart Failure 2002
Uncovering a hidden epidemic
325,000 men & women with CHF 200,000 more with “latent” HF 100,000+ hospital admissions 1 million+ days of hospital stay $1 billion+ health care costs
New drugs in chronic heart failure
diureticdigoxin
diureticdigoxinACE-I
diureticdigoxinACE-I
diureticdigoxinACE-I blocker
diureticdigoxinACE-I blocker
diureticdigoxinACE-I blockerARB
SOLVD-Trial (1991)
Risk of death ↓ 23% CIBIS-2 Trial (1999)
Risk of death ↓ 33%
0
5
10
15
20
CHARM TRIAL (2003)
Risk of death ↓ 30%
The impact of new drugs in CHF
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
2.2
2.4
1986 1988 1990 1992 1994 1996 1998 2000 2002
Year of admission
Ye
ars
of
surv
iva
l (95
%C
I)
Jhund, McIntyre, McMurray (unpublished)
Men
Women
Men andWomen
SOLVD-TEnalapril
US Carvedilol
RALES Spironoalactone
Survival after 1st CHF admission in Scotland
New devices in chronic heart failure
While cardiac transplantation is a “niche” treatment, more focus on implanting:
♥ “Smart” pacing wires to synchronise the heart’s pumping action
♥ “Automated” defibrillators to start the heart when it stops
♥ “Assist” devices that “turbo-charge” blood flow in the heart
♥ New cells to re-grow the heart
Right AtrialLead
Right VentricularLead
Left VentricularLead
Impact of devices in chronic heart failure: Companion Study
Impact of devices in chronic heart failure: SCD-HeFT Study
Months of Follow-Up
Mo
rtal
ity
Rat
e
483624120
Amiodarone
PlaceboICD
0.4
0.3
0.2
0.1
0.0
60
No. at RiskAmiodarone 845 772 715 484 280 97Placebo 847 797 724 505 304 89ICD 829 778 733 501 304 103
Hazard Ratio (97.5% Cl) P-ValueAmiodarone vs. Placebo 1.06 (0.86-1.30) 0.53ICD vs. Placebo 0.77 (0.62-0.96) 0.007
Bardy GH. N Engl J Med. 2005;352:225-237.
Chronic heart failure: an increasing economic burden
0.0 0.5 1.0 1.5 2.0
UK (2000)
NL (1988)
USA (1989)
France (1990)
UK (1991)
Sweden (1996)
Percentage of total health care expenditure
$US 9b (71%)
SEK 2579m (74%)
FF 11.4b (64%)
£UK 360m (60%)
£UK 1042m (70%)
NLG 444m (67%)
Drugs 18%
Primary Care 6% 7% Outpatient Dept
69% - Hospital Admissions
CHF-related Healthcare Expenditure
Cost of Devices for 1000’s of patients??
Presentation Overview
♥ The inevitable link between age & heart disease
♥ Chronic heart failure: an exemplar of poor outcomes, hope and plenty of costs!
♥ Back to the future: the potential value in better systems of care
Multidisciplinary, home-based intervention in CHF
♥ Home visit at 1-2 weeks post discharge by a nurse & pharmacist
♥ Clinical history and physical assessment♥ Patient education – warning signs♥ Medication management♥ Psycho-social status♥ Repeat phone calls & patient initiated calls
♥ More intensive/appropriate follow-up ♥ Promote self-care behaviour♥ Increase GP & cardiology vigilance for high risk
patients♥ Trigger long-term community management
Impact of a multidisciplinary intervention in CHF
0
100
200
300
400
500
600
0 1 2 3 4 5 6 7 8 9 10
Year of follow-up
To
tal
un
pla
nn
ed r
ead
mis
sio
ns HBI (n = 149)
UC (n = 148)
1.0
4321
0.0
0.8
0.6
0.4
0.2
0 5 7 86
Year of follow-up
All
-cau
se m
ort
alit
y
9 10
1.0
4321
0.0
0.8
0.6
0.4
0.2
0 5 7 86 9 10
Minimum follow-up
HBI (n = 149)
UC (n = 148)
HBI (n = 149)
UC (n = 148)
Cost impact of implementing what we already knew!!
Outcome per 100 patients HBI Group UC Group Difference
Survival Time 405 years 285 years 120 more life-years
Costs
Home-based Intervention $100,000 - + $100,000
Unplanned hospital stay $2,170,470 $2,367,081 - $196,611
Elective hospital stay $147,046 $103,108 - $43,938
Additional care/treatment $849,856 $589,723 + $260,133
Total Cost of Health Care $3,267,372 $3,059,912 + $207,460
Cost per life-year gained + $1728
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20% 30% 40% 50%
Percentage of all-cause recurrent stay in 122,000 patients initially admitted for heart failure in the
year 2000
Po
ten
tia
l sa
vin
gs
p.a
(£m
illi
on
)
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20% 30% 40% 50%
Po
ten
tia
l sa
vin
gs
p.a
(£m
illi
on
)
Total cost of optimal heartfailure management *
Expected reduction in recurrenthospital stay due to optimal management
An economic blue-print for optimal CHF management
Stewart et al. Eur Heart J 2002
1 device = 1 team& 250 patients!!!!
Multiple targets along the “heart health” continuum
High Risk Individuals with sub-clinical CVD
Early/milderforms of CVD
Chronic/severeforms of CVD
Delay onset Slow progression
Dise
ase f
ree
CVD
fata
lity
Minimise severity
High Risk Individuals with sub-clinical CVD
Early/milderforms of CVD
Chronic/severeforms of CVD
Delay onset Slow progression
Dise
ase f
ree
CVD
fata
lity
Minimise severity
KEY ISSUES TO IMPROVE HEALTH OUTCOMES:
♥ Cost-effective early detection at community level♥ Key targets (smoking, HT, metabolic syndrome)♥ Platform for introducing new therapeutics♥ Developing the evidence♥ Re-align health care flexible systems of care
Summary
Key challenges to the “heart health” of Australia:
♥ Improve flow of information on evolving epidemic: geo-mapping & linked data
♥ Picking the right individuals for more expensive therapies
♥ Going back to “basics” to apply what we already know will improve outcomes!